Foot Dorsal Structures PDF

FOOT: DORSAL STRUCTURES Dorsal Interossei The dorsal interossei are bipennate muscles, each with two heads. Their action occurs relative to the midline of the foot (second digit). Although the majority of the intrinsic lumbrical muscles lie on the plantar aspect of the foot, they may be indirectly...

FOOT: DORSAL STRUCTURES Dorsal Interossei The dorsal interossei are bipennate muscles, each with two heads. Their action occurs relative to the midline of the foot (second digit). Although the majority of the intrinsic lumbrical muscles lie on the plantar aspect of the foot, they may be indirectly palpated along with the dorsal interossei as a group between the metatarsal bones. Origin: Metatarsal bones (1-4) Insertion: First: Medial surface of the second proximal phalange and extensor digitorum tendons Second to fourth: Proximal phalanges and extensor digitorum tendons Action: Toe abduction and metatarsophalangeal (MP) joint extension Innervation: S2-S3 (lateral plantar nerve) Dorsal interossei Palpation Procedure • Place the foot in a relaxed position. plantar aspect of the forefoot with • Stabilize the04.01/532003/JG/R2 E6296/Speicher/Fig. one hand. • With the other hand, apply moderate pressure between the metatarsals with the fingers. • Palpate the entire length of the dorsal interossei along the metatarsal shaft. • Note the location of any tender points or fasciculatory response along the muscle. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. PRT Clinician Procedure • The patient is prone with the knee flexed to 90° and the shin supported with either your thigh or a bolster. • With the ulnar aspect of your far hand or forearm, apply downward compression over the forefoot, moving the ankle into dorsiflexion. • Use the fingers of your near hand to assess and monitor the treatment position and fasciculatory response. • Apply eversion and inversion of the forefoot with your far hand or forearm (a greater amount of inversion for the first through third metatarsals and eversion for the fourth and fifth metatarsals). • Alternate: Grasp the lateral forefoot with your far hand for positioning and force application. • Corollary tissues treated: Metatarsals 50 Dorsal interossei palpation procedure. Dorsal interossei PRT clinician procedure. See video 4.1 for the dorsal interossei PRT procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. FOOT: DORSAL STRUCTURES Cuneiforms Talus Cuneiforms Navicular Tuberosity Calcaneus Three cuneiforms comprise the midfoot. Each lies behind its respective metatarsal (the first cuneiform behind the first metatarsal, and so on), and all communicate with the navicular bone. The first cuneiform serves as an attachment site for the tibialis anterior and tibialis posterior muscles. The cuneiforms are a common site of midfoot ligament sprains. Superior Palpation Procedure • PlaceE6296/Speicher/Fig. the foot in slight04.02/532006/JG/R2 dorsiflexion to relax the extensor structures of the dorsal foot. • Palpate the shaft of the first metatarsal up to its proximal base. • Glide your fingers just over the joint space or valley between the first metatarsal proximal base and the first cuneiform. • Moving medially onto the second, or middle, cuneiform, you will feel a distinct rise as you gain the ridge of the second cuneiform. • Continue to slide your fingers laterally off the ridge of the middle cuneiform and into the next valley, where you will find the third, or lateral, cuneiform behind the third metatarsal. • Note the location of any tender points or fasciculatory response between and over the cuneiforms. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. PRT Clinician Procedure • The patient is prone with the knee flexed to 90° and the shin supported with either your thigh or a bolster. • With your far hand or forearm, apply downward compression over the midfoot, moving the ankle into dorsiflexion. • Apply eversion and inversion of the midfoot with your far hand or forearm (greater inversion for the first and second cuneiforms, less for the third) for fine-tuning. • Alternate: Grasp the midfoot with your far hand for positioning. • Corollary tissues treated: Cuneiform interosseous ligaments and talus Cuneiform palpation procedure. Cuneiform PRT clinician procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 51 FOOT: DORSAL STRUCTURES Talus The talus is a cube-shaped bone with a body, neck, and head configuration. The posterior portion of the talus is narrower than the front, and when the ankle is dorsiflexed, a wedge is formed within the talocrural joint. This moves the ankle into a closed-pack position, increasing the stability of the ankle and limiting inversion and eversion. Talus Navicular Cuneiforms Sesamoid Sustentaculum tali Calcaneus Medial Palpation Procedure E6296/Speicher/Fig. 04.03/532009/JG/R1 • Place the ankle in a relaxed open-pack position (plantar flexion). • Place your fingers at the center of the ankle joint at the level of the malleoli between the extensor tendons. This location is over the anterior dome of the talus. • While palpating on the bony surface of the talus, move the ankle through dorsiflexion and plantar flexion to feel the roll of the anterior dome. • The medial and lateral heads of the talus can be palpated by sliding the fingers in either direction from its anterior dome. To expose each head more fully, invert the foot to expose the lateral head and apply eversion to expose the medial head. Also, the medial head is located just proximal to the navicular tubercle. • Note the location of any tender points or fasciculatory response over the talus. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. PRT Clinician Procedure • The patient is prone with the knee flexed between 60 and 90° and the shin supported with either your thigh or a bolster. • Grasp the calcaneus with your far hand and apply compression downward while moving the ankle into dorsiflexion. • Apply inversion, eversion, and rotation with your far hand to fine-tune the treatment location. • Corollary tissues treated: Extensor digitorum tendons 52 Talus palpation procedure. Talus PRT clinician procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. FOOT: DORSAL STRUCTURES Extensor Digitorum Longus Tendons The four extensor digitorum longus tendons are lateral to the extensor hallucis longus tendons on the dorsal foot and come together proximal to the ankle joint to form the common tendon of the extensor digitorum longus muscle. This muscle is sandwiched between the tibialis anterior and peroneal muscles. Superior extensor retinaculum Extensor hallucis longus Inferior peroneal retinaculum Inferior extensor retinaculum Extensor hallucis brevis Extensor digitorum brevis Anterior Origin: Lateral tibial condyle, upper three quarters of the medial shaft of the fibula, interosseous membrane, deep crural fascia Insertion: Second through fifth middle and distal phalanges Action: Extension of toes 2 through 5, ankle dorsiflexion (accessory), foot eversion (accessory) Innervation: L5-S1 (deep peroneal nerve) E6296/Speicher/Fig. 04.04/532012/JG/R1 Palpation Procedure • Place the ankle and foot in a relaxed but slightly dorsiflexed position. • Ask the patient to dorsiflex the ankle and extend the toes to visibly bring out the extensor tendons. • Either pince or strum over the tendons. • Note the location of any tender points or fasciculatory response between and over the tendons. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. PRT Clinician Procedure • The patient is prone with the knee flexed to 90° and the shin supported with either your thigh or a bolster. • Grasp the calcaneus with your far hand and place the forearm of the same hand on the plantar foot with an emphasis on the second through fifth metatarsals, or rays. • Move the foot into dorsiflexion and apply toe extension with forearm pressure. • Apply eversion and inversion to the foot with your far forearm for fine-tuning. • Corollary tissues treated: Cuneiform interosseous ligaments, extensor hallucis longus Extensor digitorum longus tendon palpation procedure. Extensor digitorum longus tendon PRT clinician procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 53 FOOT: DORSAL STRUCTURES Extensor Digitorum Brevis Peroneus longus Peroneus brevis Extensor digitorum longus Peroneus tertius Superior extensor retinaculum Inferior extensor retinaculum Superior peroneal retinaculum Inferior peroneal retinaculum Extensor digitorum brevis Lateral The extensor digitorum brevis muscle belly lies beneath the extensor digitorum longus tendons approximately 2 cm (about 3/4 in.) anterior to the lateral malleolus on the dorsolateral aspect of the foot. When the toes and ankle are extended, the small, round belly of this muscle becomes visible. Origin: Dorsal surface of the calcaneus, lateral talocalcaneal ligament, inferior aspect of the extensor retinaculum Insertion: Second through fourth toes via the extensor tendon longus tendons. Some consider the extensor hallucis tendon a part of the extensor digitorum brevis. Action: Second through fourth MP extension, great toe MP extension Innervation: L5-S1 (lateral branch of the deep peroneal nerve) E6296/Speicher/Fig. 04.05/532015/JG/R2 Palpation Procedure • Place the ankle and foot in a relaxed but slightly dorsiflexed position. • Move approximately 4 cm (1.5 in.) distal from the lateral malleolus toward the fifth toe while moving under the extensor tendons. • Ask the patient to extend the toes and ankle along with eversion to bring the muscle belly of the extensor digitorum brevis out over the cuboid. • Note the location of any tender points or fasciculatory response over the muscle. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. PRT Clinician Procedure • The patient is prone with the knee flexed to 90° and the shin supported with either your thigh or a bolster. • Grasp the heel with your far hand and place your wrist and forearm of the same hand on the plantar foot. • Move the ankle into dorsiflexion and marked eversion with the far hand, wrist, and forearm. • Rotate externally and apply a compressive force downward with the far hand, wrist, and forearm. Extensor digitorum brevis palpation procedure. Extensor digitorum brevis PRT clinician procedure. • Corollary tissues treated: Peroneal tendons 54 T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. FOOT: PLANTAR STRUCTURES Plantar Aponeurosis The plantar aponeurosis, also known as the plantar fascia, is a dense triangular avascular connective tissue that covers the majority of the foot’s plantar muscles. The plantar fascia stabilizes the arch during ambulation. Origin: Plantar aspect of the calcaneus. The central portion originates at the medial calcaneal tubercle, which is a common site for irritation. Insertion: Proximal phalanx on each side of the toes Plantar fascia Action: Stabilizes the arch through the windlass mechanism; assists in stabilizing the calcaneus during push-off during the gait cycle Innervation: S1-S2 (tibial nerve, medial and lateral branches) Calcaneus Plantar view E6296/Speicher/Fig. Palpation Procedure 04.06/532018/JG/R1 • Place the patient in a prone position with the foot in a relaxed position. • Ask the patient to pull the big toe toward the shin to accentuate the fibers of the plantar aponeurosis for palpation. • Strum across the aponeurosis with firm pressure from its distal insertions to its proximal origin at the medial calcaneus. • Note the location of any tender points or fasciculatory response of the tissue, particularly at its origin at the calcaneus. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. Plantar aponeurosis palpation procedure. > continued T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 55 FOOT: PLANTAR STRUCTURES Plantar Aponeurosis > continued PRT Clinician Procedure • The patient is prone with knee flexed to ~60° and the shin supported with either your thigh or a bolster. • Place the toes in the sulcus of your dominant shoulder to promote phalangeal flexion. • Move the ankle into marked plantar flexion with your far hand. • Apply calcaneal caudal traction with the far hand. • Apply calcaneal eversion or inversion based on the location of the lesion with the far hand. • Also with the far hand, apply calcaneal internal or external rotation based on the location of the lesion. • Corollary tissues treated: Quadratus plantae, flexor digitorum brevis, flexor digitorum longus Plantar aponeurosis PRT clinician procedure. See video 4.2 for the plantar aponeurosis PRT procedure. Patient Self-Treatment Procedure • If there is adequate flexibility at the knee and hip, place the foot on the opposite thigh. If there is not enough flexibility to accomplish this positioning, place the foot on the opposite shin. • Grasp the dorsal forefoot and toes, moving them into flexion and abduction with a cupping or cradling mechanism. • Place the fingers of the other hand over the anterior aspect of the ankle and the thumb of the same hand at the back of the heel. • While flexing and compressing the forefoot and toes inward, translate the calcaneus toward the toes to encourage relaxation of the plantar fascia. If a finger of either hand can reach the area of tenderness, place it over this area to ascertain the fasciculatory response of the tissue. 56 Plantar aponeurosis patient self-treatment procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. FOOT: PLANTAR STRUCTURES Flexor Hallucis Brevis Adductor hallucis: Transverse head Oblique head Flexor hallucis brevis Flexor digiti minimi The plantar muscles are arranged in four layers from superficial to deep based on the covering of them by the plantar fascia; the longer muscles are closer to the fascia. Even though the flexor hallucis brevis muscle is located within the deep third layer, its contraction can be palpated by having the patient flex the big toe against resistance. Origin: Plantar cuboid and third cuneiform surfaces, posterior tibialis tendon, medial intermuscular septum Insertion: Medial and lateral surfaces of the proximal phalanx of the first toe Action: First toe MP flexion and abduction Innervation: S1-S2 (medial plantar nerve) Third plantar layer E6296/Speicher/Fig. 04.07/532022/JG/R2 Palpation Procedure • The patient is prone with the foot in a relaxed position. • Strum across the flexor hallucis brevis proximal to the first metatarsal head, moving toward the plantar navicular. • Note the location of any tender points or fasciculatory response of the muscle. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. Flexor hallucis brevis palpation procedure. > continued T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 57 FOOT: PLANTAR STRUCTURES Flexor Hallucis Brevis > continued PRT Clinician Procedure • Place the toes and forefoot in the sulcus of your hip to promote phalangeal flexion. • Place the ankle in marked plantar flexion. • Apply calcaneal caudal traction with your far hand while placing the forefinger of the same hand over the flexor hallucis brevis, if possible. • Place the first metatarsal into plantar flexion with your near hand while applying inward rotation. • Both hands can apply a valgus force using the fore- and hindfoot for fine-tuning. • Corollary tissues treated: Plantar fascia, quadratus plantae, flexor digitorum brevis and longus, flexor hallucis longus, plantar interossei, lumbricals Flexor hallucis brevis PRT clinician procedure. See video 4.3 for the flexor hallucis brevis PRT procedure. Patient Self-Treatment Procedure Use the plantar fascia self-treatment with the exception of emphasizing first metatarsal plantar flexion and rotation. Flexor hallucis brevis patient selftreatment procedure. 58 T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. FOOT: PLANTAR STRUCTURES Abductor Hallucis The abductor hallucis muscle helps to form the medial arch of the foot and is one of the plantar muscles that is most easily palpable. Some people can abduct the great toe, which brings out the abductor hallucis’ distinct muscle belly. Flexor hallucis brevis Flexor digiti minimi Abductor hallucis Quadratus plantae Origin: Medial calcaneal tuberosity, plantar aponeurosis, flexor retinaculum Insertion: Base of the medial side of the first proximal phalanx, medial sesamoid, flexor hallucis brevis tendon Action: Big toe MP abduction and flexion Innervation: S1-S2 (medial plantar nerve) Second plantar layer 04.08/532026/JG/R1 PalpationE6296/Speicher/Fig. Procedure • Place the foot in relaxed plantar-flexed position off the end of the treatment table or on your thigh. • Palpate the bulk of this muscle at the posterior aspect of the medial heel and trace it forward to the big toe. • Plantar flexion of the big toe against resistance will bring out the muscle belly for palpation. • Note the location of any tender points or fasciculatory response at the muscle and its attachments. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. Abductor hallucis palpation procedure. > continued T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 59 FOOT: PLANTAR STRUCTURES Abductor Hallucis > continued PRT Clinician Procedure • The patient is prone with the knee flexed to ~60° and the ankle on your thigh. • Place the ankle in marked plantar flexion. • Grasp the heel with your near hand and the forefoot with your far hand to apply a valgus force at the midfoot. • Use a finger from either hand to monitor the tissue lesion. • While applying the valgus force, invert the heel with your near hand. • Apply compression of the calcaneus toward the toes with your near hand. • Rotate the first ray into flexion and internal rotation with your far hand. • Corollary tissues treated: Plantar navicular, plantar fascia, quadratus plantae, flexor digitorum brevis and longus, flexor hallucis longus, plantar interossei, lumbricals Abductor hallucis PRT clinician procedure. Patient Self-Treatment Procedure Use the self-treatment procedure for the plantar fascia, but focus on inverting the calcaneus while applying a valgus force at the forefoot while rotating the first ray into flexion and internal rotation. 60 Abductor hallucis patient self-treatment procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. FOOT: PLANTAR STRUCTURES Abductor Digiti Minimi The abductor digiti minimi is a superficial muscle that lies along the lateral border of the foot. Its orientation along the fifth toe and metatarsal allows it to both flex and abduct the fifth toe. Flexor hallucis brevis Flexor digiti minimi Flexor digitorum brevis Abductor digiti minimi Abductor hallucis Origin: Lateral and medial calcaneal processes of the tuberosity, plantar aponeurosis, intermuscular septum Insertion: Lateral aspect at the base of the fifth proximal phalanx Action: Abducts the big toe, flexes the fifth MP Innervation: S1-S3 (lateral plantar nerve) First plantar layer E6296/Speicher/Fig. Palpation Procedure 04.09/532030/JG/R1 • Place the foot in a relaxed plantar-flexed position off the end of the treatment table or on your thigh. • Palpate this muscle between the lateral heel and lateral plantar surface of the fifth toe. • Abduction and flexion of the fifth toe against resistance will accentuate the contraction of this muscle for palpation. • Note the location of any tender points or fasciculatory response of the muscle and its attachments. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) at the location throughout the PRT treatment procedure until reassessment has occurred. Abductor digiti minimi palpation procedure. > continued T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 61 FOOT: PLANTAR STRUCTURES Abductor Digiti Minimi > continued PRT Clinician Procedure • Position the patient prone with the ankle flexed on your thigh. • Place the ankle in slight plantar flexion. • With your near hand at the forefoot, grasp the heel with your other hand and use a finger from either hand to monitor the lesion. • Apply compression of the heel toward the toes with your far hand to promote phalangeal flexion. • Using both hands, apply a varus force to the midfoot by adducting the forefoot and hindfoot (the fifth ray should approximate toward the calcaneus). • Internally rotate the forefoot with the near hand for fine-tuning. • Corollary tissues treated: Plantar cuboid, plantar fascia, quadratus plantae, flexor digitorum longus Abductor digiti minimi PRT clinician procedure. See video 4.4 for the abductor digiti minimi PRT procedure. Patient Self-Treatment Procedure Use the self-treatment procedure for the plantar fascia, but focus on compressing the heel toward the toes while flexing, adducting, and rotating the forefoot towards the heel. Abductor digiti minimi patient selftreatment procedure. 62 T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. FOOT: PLANTAR STRUCTURES Plantar Interossei and Lumbricals The plantar interossei and lumbricals are deep intrinsic muscles that lie on the plantar surface of the metatarsals rather than between them, as seen with the dorsal interossei. They have been grouped here because the PRT treatment of these muscles affects the release of both. Deep palpation over these structures elicits their tenderness, and their fasciculation will be felt during treatment. Origin: Plantar interossei: Plantar surface of the third through fifth metatarsals Lumbricals: Flexor digitorum longus tendon Insertion: Plantar interossei: Medial side of the proximal phalange of the same toe, dorsal digital expansion Lumbricals: Proximal second through fifth phalanges, dorsal expansion of the extensor digitorum longus tendons Plantar interossei E6296/Speicher/Fig. 04.10a/532034/JG/R2 1st lumbrical 2nd lumbrical 3rd lumbrical Action: Plantar interossei: Third through fifth toe adduction, MP flexion; assists interphalangeal (IP) extension Lumbricals: Second through fifth metacarpal phalangeal (MP) flexion; assists proximal interphalangeal (PIP) and distal interphalangeal (DIP) extension Innervation: Plantar interossei: S2-S3 (lateral plantar nerve) 4th lumbrical First lumbrical: L5-S1 (medial plantar nerve) Second through fourth lumbricals: S2-S3 (deep branch of the lateral plantar nerve) Second plantar layer > continued E6296/Speicher/Fig. 4.10b/531993/JG/R1 T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics. 63 FOOT: PLANTAR STRUCTURES Plantar Interossei and Lumbricals > continued Palpation Procedure • Place the foot in a relaxed plantar-flexed position off the end of the treatment table or on your thigh. • Palpate the density or firmness of the muscle contraction for these tissues over the plantar surfaces of the metatarsals while the patient flexes the toes against resistance. • Note the location of any tender points or fasciculatory response of the muscles and over the metatarsal shafts. • Once you have determined the most dominant tender point or fasciculation (or both), maintain light pressure with the pad(s) of the finger(s) or the thumbs at the location throughout the PRT treatment procedure until reassessment has occurred. PRT Clinician Procedure • The patient is prone with the knee flexed to ~60° with the ankle on your thigh. • Cup the forefoot with your far hand while resting the dorsum of the foot on your thigh in maximal plantar flexion while your near hand monitors the lesion. • Compress the metatarsal shafts together with your far hand while applying toe flexion. • Apply rotation for fine-tuning with the far hand. • Corollary tissues treated: Flexor digitorum brevis and longus, flexor hallucis longus and brevis Plantar interossei and lumbricals palpation procedure. Plantar interossei and lumbricals PRT clinician procedure. See video 4.5 for the plantar interossei and lumbricals PRT procedure. Patient Self-Treatment Procedure • Use the self-treatment procedure for the plantar fascia, but do not translate the heel toward the toes. • The focus of the positioning should be on compressing the metatarsal shafts toward one another while applying toe flexion and rotation. 64 Plantar interossei and lumbricals patient self-treatment procedure. T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 2–Sport Medics.